If you would like to download a PDF version of the evaluation form to print out and bring in at the time of your first appointment INSTEAD of filling it out online, please click HERE.

Evalution Form

Step 1 of 9

11%

DAVID L. FOGELSON, M.D., Inc.

Psychiatry

2730 Wilshire Boulevard, Suite 325, Santa Monica, California 90403

Telephone: (310) 828-5015

Fax: (310) 829-3877

E-mail: DFOGELSO@UCLA.EDU

Welcome to our office!

Thank you for making an appointment with Dr. Fogelson. Thank you for taking the time to complete this important questionnaire and forwarding it to us prior to your appointment. Please be sure to fill out all pages. Directions and a map indicating the location of the office may be found on this website.

We want you to understand our medical specialty and to feel comfortable in our office. The pamphlets on the National Institute of Mental Health's website may answer some questions for you. Other areas of this website explain office procedures. Please feel free to ask Dr. Fogelson or myself any questions that may remain unanswered.

Dr. Fogelson received his medical degree from Harvard Medical School and his graduate training in Psychiatry from UCLA. He is a Clinical Professor in the UCLA Department of Psychiatry and Biobehavioral Sciences. Dr. Fogelson is a general psychiatrist for adults. He specializes in medication treatments and psychotherapy.

Dr. Fogelson and I look forward to meeting you.

Sincerely,
Administrative Coordinator

P.S. If the doors to the building are locked, please use the breezeway entrance along the side of the building. You can let yourself into the building by entering the code 7353.

David L. Fogelson, M.D., Inc.

Consent for Evaluation or Treatment

Please take a moment to review some information to which you are entitled before receiving psychiatric services.

Any information you disclose will be maintained in the strictest confidence, unless you specifically authorize its release, or unless its release is required by law or professional standards of practice. In particular, your right to confidentiality may not be maintained if you are an immediate danger to yourself or to someone else, and steps must be taken to assure your own or another’s safety. Also, any clinician hearing about domestic violence from a patient or that a child or elder is being or has been physically or psychologically abused is required by law to report this information to a designated agency. If it is necessary to disclose some information you have provided, to anyone else, this will be discussed with you.

All outpatient visits must be paid for at the time of the visit. Dr. Fogelson is not a provider for any of the insurance networks. At the time of your outpatient visit, you will be provided with an insurance statement to submit to your insurance company. We cannot accept responsibility for negotiating claims with insurance companies or other persons. You are responsible for payment of your medical care regardless of the status of your claim. Any other financial arrangement must be made with us prior to service.

It is important for your continued medical care that you have routine follow up appointments so that the doctor can monitor your care. Therefore, if you have not returned to see the doctor by three months after the date of recommended return to the office, we will consider the doctor patient relationship terminated and no prescription refills will be granted after this period.

Any outstanding bills will be rebilled monthly. If payment is not received after two successive billings, your account may be sent to a collection service. Should you need to cancel a session, please do so at least 48 business hours in advance. Otherwise you will be charged at your regular rate for the cancelled session. Under circumstances where a party other than the patient is responsible for payment, that party must sign a separate agreement guaranteeing payment of the bill.

There is a returned check charge of $20.00.

I agree in the event of non-payment to bear the cost of collection and/or court costs and legal fees should this be required.

I have read and understood the foregoing, and I consent to this evaluation or treatment.

Check This Box To Agree*

I Agree To The Terms Above

NEW PATIENT INFORMATION RECORD

Name

FirstLast

Referred By

Driver's Licenses Number

Martial Status

Date of Birth

Age

Address

Street AddressAddress Line 2CityStateZIP Code

Home Phone

Cell Phone

Email

Employed By or Retired From

Occupation (Or Student)

How Long?

Business Phone

Employer's Street Address

Street AddressAddress Line 2CityStateZIP Code

Person Responsible For Payment

Name

Street AddressCityStateZIP Code

Home Phone

Referring Clinician, Agency, or Friend

Referring Clinician, Agency, or Friend

It is optional to provide a referring friend's contact information.

Street AddressCityStateZIP Code

Phone

Fax

Email

Person To Contact In Case of Emergency

Name

Relationship

Home Phone

Cell Phone

Is this persons address the same as yours?

Yes

No

Address

Street AddressAddress Line 2CityStateZIP Code

Personal Medical History

TO BE FILLED OUT BY PATIENT (Please complete the following to the best of your ability)

Do you receive regular medical care from a physician or clinic?*

Yes

No

Name of Physician or Clinic

Phone

Fax

Email

Street AddressCityStateZIP Code

Have you ever had any of the following illnesses?*

High Blood Pressure

Diabetes

Cancer

Thyroid Disease

Other Hormone Problem

Alcoholism

Gonorrhea

Syphilis

Epilepsy

Migraine Headaches

Peptic Ulcer (Stomach Ulcer)

Colitis

Meningitis or Encephalitis

Tuberculosis

Stroke

Rheumatic Fever

Asthma

Birth Defects

Please Check all That apply

Do you suffer from any chronic, non-psychiatric, medical diseases?*

Yes

No

If yes, please list the name of the disease(s) and date(s) of onset.

What is your current weight? (Estimate if you do not know exactly)

In LBS

What is the most you have ever weighed?

When?

Can you explain any recent weight loss or weight gain?

Have you ever had to be hospitalized?*

Yes

No

If yes, complete the following

Year

Doctor’s Name

Name of Hospital

Reason

Have you ever had surgery or been advised to have surgery?*

Yes

No

If yes, complete the following

Year

Doctor’s Name

Name of Hospital

Name of Operation/Procedure

Have You Ever Had Any Injuries*

Yes

No

Check All Injuries That Apply*

Head Injury

Concussion (Ever been knocked unconscious)

Food, Chemical, Drug Poisoning

Broken Bones

Severe Cuts or Lacerations

Other:

If Other Please List here:

How Did Your Injury Happen?

Head Injury

How Did Your Injury Happen?

Concussion (Ever been knocked unconscious)

How Did Your Injury Happen?

Food, Chemical, Drug Poisoning

How Did Your Injury Happen?

Broken Bones

How Did Your Injury Happen?

Severe Cuts or Lacerations

How Did Your Injury Happen?

Other:

Do you have any allergies?*

Hay Fever

Penicillin

Other Medication:

None

Check all that apply

Please list Other Medications Here

How are you affected?

Hay Fever

How are you affected?

Penicillin

How are you affected?

Other Medication:

Have you recently had any of the following tests?

Physical Exam*

Yes

No

When

Where

Results

Blood Tests*

Yes

No

When

Where

Results

Chest X-Ray*

Yes

No

When

Where

Results

TB Skin Test (PPD)*

Yes

No

When

Where

Results

Electrocardiogram (EKG)*

Yes

No

When

Where

Results

Brain Scan or EMI*

Yes

No

When

Where

Results

EEG*

Yes

No

When

Where

Results

Are you in the habit of using any of the following items?

Coffee (Cups/Day)*

Yes

No

Amount Currently Using

Most Ever Used

Cigarettes (Packs/Day)*

Yes

No

Amount Currently Using

Most Ever Used

Alcohol (Amounts/Types of Alcohol Used Daily)*

Yes

No

Amount Currently Using

Most Ever Used

Marijuana (Joints/Day)*

Yes

No

Amount Currently Using

Most Ever Used

Vitamins*

Yes

No

Amount Currently Using

Most Ever Used

Sleeping Pills*

Yes

No

Amount Currently Using

Most Ever Used

Glue or Paint Inhalation*

Yes

No

Amount Currently Using

Most Ever Used

Aspirin*

Yes

No

Amount Currently Using

Most Ever Used

Laxatives*

Yes

No

Amount Currently Using

Most Ever Used

Are you currently on any medication?*

Yes

No

If yes, please give name and dosage

Personal Psychiatric History

Have you ever received any previous psychiatric or psychological evaluation or treatment?*

Involved in a personal injury, or workman’s compensation or medical malpractice lawsuit

To your knowledge, have you ever been exposed to any toxic chemicals

None

Check ALL that apply

Have you ever had the experience of:*

Finding yourself in a place and having no idea how you got there

Minutes, hours or days having gone by without any memory of what has happened during that time

Having no memory for some important events in your life (for example, a graduation, wedding, death)

None

Check ALL that apply

Do you ever have irresistible urges to:*

Hurt, attack or kill someone

Throw, break, destroy property

Steal objects you don’t need for personal use or monetary value

Gamble, whether you can afford to or not

Deliberately set fires

Deliberately pull your hair out

None

Check ALL that apply

Please Elaborate

Recent stressful life events (in last 2 years):*

Marriage or engagement

Separation or divorce

Breakup of important relationship

Death of close family, friend

Child left home

Bad health of family, friend

Personal injury or illness

Sexual difficulties

Changes in school, work

Changes in residence

Financial disorder

Legal difficulties

None

Check ALL that apply

Personality Questionnaire

These questions are about the kind of person you are generally are-that is, how you have usually felt or behaved over the past several years. Check “YES” if the question completely or mostly applies to you, or check “NO” if it does not apply to you. If you do not understand a question or are not sure of your answer, check "UNSURE".

Have you avoided jobs or tasks that involved having to deal with a lot of people?*

Yes

No

Unsure

Please Elaborate

Do you avoid getting involved with people unless you are certain they will like you?*

Yes

No

Unsure

Please Elaborate

Do you find it hard to be “open” even with people you are close to?*

Yes

No

Unsure

Please Elaborate

Do you often worry about being criticized or rejected in social situations?*

Yes

No

Unsure

Please Elaborate

Are you usually quiet when you meet new people?*

Yes

No

Unsure

Please Elaborate

Do you believe that you’re not good, as smart, or as attractive as most other people?*

Yes

No

Unsure

Please Elaborate

Are you afraid to try new things?*

Yes

No

Unsure

Please Elaborate

Do you need a lot of advice or reassurance from others before you can make everyday decisions- like what to wear or what to order in a restaurant?*

Yes

No

Unsure

Please Elaborate

Do you depend on other people to handle important areas in your life such as finances, child care, or living arrangements?*

Yes

No

Unsure

Please Elaborate

Do you find it hard to disagree with people even when you think they are wrong?*

Yes

No

Unsure

Please Elaborate

Do you find it hard to start or work on tasks when there is no one to help you?*

Yes

No

Unsure

Please Elaborate

Have you often volunteered to do things that are unpleasant?*

Yes

No

Unsure

Please Elaborate

Do you usually feel uncomfortable when you are by yourself?*

Yes

No

Unsure

Please Elaborate

When a close relationship ends, do you feel you immediately have to find someone else to take care of you?*

Yes

No

Unsure

Please Elaborate

Do you worry a lot about being left alone to take care of yourself?*

Yes

No

Unsure

Please Elaborate

Are you the kind of person who focuses on details, order, and organization or likes to make lists and schedules?*

Yes

No

Unsure

Please Elaborate

Do you have trouble finishing jobs because you spend so much time trying to get things exactly right?*

Yes

No

Unsure

Please Elaborate

Do you or other people feel that you are so devoted to work (or school) tha t you have no time left for anyone else or for just having fun?*

Yes

No

Unsure

Please Elaborate

Do you have very high standards about what is right and what is wrong?*

Yes

No

Unsure

Please Elaborate

Do you have trouble throwing things out because they might come in handy some day?*

Yes

No

Unsure

Please Elaborate

Is it hard for you to let other people help you unless they agree to do things exactly the way you want?*

Yes

No

Unsure

Please Elaborate

Is it hard for you to spend money on yourself and other people even when you have enough?*

Yes

No

Unsure

Please Elaborate

Are you often so sure you are right that it doesn’t matter what other people say?*

Yes

No

Unsure

Please Elaborate

Have other people told you that are stubborn or rigid?*

Yes

No

Unsure

Please Elaborate

When someone asks you to do something that you don’t want to do, do you say “yes” but then work slowly or do a bad job?*

Yes

No

Unsure

Please Elaborate

If you don’t want to do something, do you often just “forget” to do it?*

Yes

No

Unsure

Please Elaborate

Do you often feel that other people don’t understand you, or don’t appreciate how much you do?*

Yes

No

Unsure

Please Elaborate

Are you often grumpy and likely to get into arguments?*

Yes

No

Unsure

Please Elaborate

Have you found that most of your bosses, teachers, supervisors, doctors, and others who are supposed to know what they are doing really don’t?*

Yes

No

Unsure

Please Elaborate

Do you often think that it’s not fair that other people have more than you do?*

Yes

No

Unsure

Please Elaborate

Do you often complain that more than your share of bad things have happened to you?*

Yes

No

Unsure

Please Elaborate

Do you often angrily refuse to do what others want and then later feel bad and apologize?*

Yes

No

Unsure

Please Elaborate

Do you usually feel unhappy or that life is no fun?*

Yes

No

Unsure

Please Elaborate

Do you believe that you are basically an inadequate person and often don’t feel good about yourself?*

Yes

No

Unsure

Please Elaborate

Do you often put yourself down?*

Yes

No

Unsure

Please Elaborate

Do you keep thinking about bad things that have happened in the past or worry about bad things that might happen in the future?*

Yes

No

Unsure

Please Elaborate

Do you often judge others harshly and easily find fault with them?*

Yes

No

Unsure

Please Elaborate

Do you think that most people are basically no good?*

Yes

No

Unsure

Please Elaborate

Do you almost always expect things to turn out badly?*

Yes

No

Unsure

Please Elaborate

Do you often feel guilty about things you have or haven’t done?*

Yes

No

Unsure

Please Elaborate

Do you often have to keep an eye out to stop people from using you or hurting you?*

Yes

No

Unsure

Please Elaborate

Do you spend a lot of time wondering if you can trust your friends or the people you work with?*

Yes

No

Unsure

Please Elaborate

Do you find that it is best not to let other people know much about you because they will use it against you?*

Yes

No

Unsure

Please Elaborate

Do you often detect hidden threats or insults in things people say or do?*

Yes

No

Unsure

Please Elaborate

Are you the kind of person who holds grudges or takes a long time to forgive people who have insulted or slighted you?*

Yes

No

Unsure

Please Elaborate

Are there many people you can’t forgive because they did or said something to you a long time ago?*

Yes

No

Unsure

Please Elaborate

Do you often get angry or lash out when someone criticizes or insults you in some way?*

Yes

No

Unsure

Please Elaborate

Have you often suspected that your spouse or partner has been unfaithful?*

Yes

No

Unsure

Please Elaborate

When you are out in public and see people talking, do you often feel that they are talking about you?*

Yes

No

Unsure

Please Elaborate

Do you often get the feeling that things that have no special meaning to most people are really meant to give you a message?*

Yes

No

Unsure

Please Elaborate

When you are around people, do you often get the feeling that you are being watched or stared at?*

Yes

No

Unsure

Please Elaborate

Have you ever felt that you could make things happen just by making a wish or thinking about them?*

Yes

No

Unsure

Please Elaborate

Have you had personal experiences with the supernatural?*

Yes

No

Unsure

Please Elaborate

Do you believe that you have a “sixth sense” that allows you to know and predict things that others can’t?*

Yes

No

Unsure

Please Elaborate

Does it often seem that objects or shadows are really people or animals or that noises are actually people’s voices?*

Yes

No

Unsure

Please Elaborate

Have you had the sense that some person or force is around you, even though you cannot see anyone?*

Yes

No

Unsure

Please Elaborate

Do you often see auras or energy fields around people?*

Yes

No

Unsure

Please Elaborate

Are there very few people that you’re really close to outside of your immediate family?*

Yes

No

Unsure

Please Elaborate

Do you often feel nervous when you are with other people?*

Yes

No

Unsure

Please Elaborate

Is it NOT important to you whether you have any close relationships?*

Yes

No

Unsure

Please Elaborate

Would you almost always rather do things alone than with other people?*

Yes

No

Unsure

Please Elaborate

Could you be content without ever being sexually involved with anyone?*

Yes

No

Unsure

Please Elaborate

Are there really very few things that give you pleasure?*

Yes

No

Unsure

Please Elaborate

Does it NOT matter to you what people think of you?*

Yes

No

Unsure

Please Elaborate

Do you find that nothing makes you very happy or very sad?*

Yes

No

Unsure

Please Elaborate

Do you like to be the center of attention?*

Yes

No

Unsure

Please Elaborate

Do you flirt a lot?*

Yes

No

Unsure

Please Elaborate

Do you often find yourself “coming on” to people?*

Yes

No

Unsure

Please Elaborate

Do you try to draw attention to yourself by the way you dress or look?*

Yes

No

Unsure

Please Elaborate

Do you often make a point of being dramatic and colorful?*

Yes

No

Unsure

Please Elaborate

Do you often change your mind about things depending on the people you’re with or what you ha ve just read or seen on TV?*

Yes

No

Unsure

Please Elaborate

Do you have lots of friends that you are very close to?*

Yes

No

Unsure

Please Elaborate

Do people often fail to appreciate your very special talents or accomplishments?*

Yes

No

Unsure

Please Elaborate

Have people told you that you have too high an opinion of yourself?*

Yes

No

Unsure

Please Elaborate

Do you think a lot about the power, fame, or recognition that will be yours someday?*

Yes

No

Unsure

Please Elaborate

Do you think a lot about the perfect romance that will be yours someday?*

Yes

No

Unsure

Please Elaborate

When you have a problem, do you almost always insist on seeing the top person?*

Yes

No

Unsure

Please Elaborate

Do you feel it is important to spend time with people who are special or influential?*

Yes

No

Unsure

Please Elaborate

Is it very important to you that people pay attention to you or admire you in some way?*

Yes

No

Unsure

Please Elaborate

Do you think that it’s not necessary to follow certain rules or social conventions when they get in your way?*

Yes

No

Unsure

Please Elaborate

Do you feel that you are the kind of person who deserves special treatment?*

Yes

No

Unsure

Please Elaborate

Do you often find it necessary to step on a few toes to get what you want?*

Yes

No

Unsure

Please Elaborate

Do you often have to put your needs above other people’s?*

Yes

No

Unsure

Please Elaborate

Do you often expect other people to do what you ask without question because of who you are?*

Yes

No

Unsure

Please Elaborate

Are you NOT really interested in other people’s problems or feelings?*

Yes

No

Unsure

Please Elaborate

Have people complained to you that you don’t listen to them or care about their feelings?*

Yes

No

Unsure

Please Elaborate

Are you often envious of others?*

Yes

No

Unsure

Please Elaborate

Do you feel that others are often envious of you?*

Yes

No

Unsure

Please Elaborate

Do you find that there are very few people that are worth your time and attention?*

Yes

No

Unsure

Please Elaborate

Have you often become frantic when you thought that someone you really cared about was going to leave you?*

Yes

No

Unsure

Please Elaborate

Do your relationships with people you really care about have lots of extreme ups and downs?*

Yes

No

Unsure

Please Elaborate

Have you all of a sudden changed your sense of you are and where you are headed?*

Yes

No

Unsure

Please Elaborate

Does your sense of who you are often change dramatically?*

Yes

No

Unsure

Please Elaborate

Are you different with different people or in different situations, so that you sometimes don’t know who you really are?*

Yes

No

Unsure

Please Elaborate

Have there been lots of sudden changes in your goals, career plans, religious belief, and so on?*

Yes

No

Unsure

Please Elaborate

Have you often done things impulsively?*

Yes

No

Unsure

Please Elaborate

Have you tried to hurt or kill yourself or threatened to do so?*

Yes

No

Unsure

Please Elaborate

Have you ever cut, burned, or scratched yourself on purpose?*

Yes

No

Unsure

Please Elaborate

Do you have a lot of sudden mood changes?*

Yes

No

Unsure

Please Elaborate

Do you often feel empty inside?*

Yes

No

Unsure

Please Elaborate

Do you often have temper outbursts or get so angry that you lose control?*

Yes

No

Unsure

Please Elaborate

Do you hit people or throw things when you get angry?*

Yes

No

Unsure

Please Elaborate

Do even little things get you very angry?*

Yes

No

Unsure

Please Elaborate

When you are under a lot of stress, do you get suspicious of other people or feel especially spaced out?*

Yes

No

Unsure

Please Elaborate

Before you were 15, would you bully or threaten other kids?*

Yes

No

Unsure

Please Elaborate

Before you were 15, would you start fights?*

Yes

No

Unsure

Please Elaborate

Before you were 15, did you hurt or threaten someone with a weapon, like a bat, brick, broken bottle, knife, or gun?*

Yes

No

Unsure

Please Elaborate

Before you were 15, did you deliberately torture someone or cause someone physical pain and suffering?*

Yes

No

Unsure

Please Elaborate

Before you were 15, did you torture or hurt animals on purpose?*

Yes

No

Unsure

Please Elaborate

Before you were 15, did you rob, mug, or forcibly take something from someone by threatening him or her?*

Yes

No

Unsure

Please Elaborate

Before you were 15, did you force someone to have sex with you, to get undressed in front of you, or touch you sexually.*

Yes

No

Unsure

Please Elaborate

Before you were 15, did you set fires?*

Yes

No

Unsure

Please Elaborate

Before you were 15, did you deliberately destroy things that weren’t yours?*

Yes

No

Unsure

Please Elaborate

Before you were 15, did you break into houses, other buildings, or cars?*

Yes

No

Unsure

Please Elaborate

Before you were 15, did you lie a lot or “con” other people?*

Yes

No

Unsure

Please Elaborate

Before you were 15, did you sometimes steal or shoplift things or forge someone’s signature?*

Yes

No

Unsure

Please Elaborate

Before you were 15, did you run away from home and stay away overnight?*

Yes

No

Unsure

Please Elaborate

Before you were 13, did you often stay out very late, long after the time you were supposed to be home?*